Pregnancy loss: French clinical practice guidelines.

In intrauterine pregnancies of uncertain viability with a gestational sac without a yolk sac (with a mean of three orthogonal transvaginal ultrasound measurements <25mm), the suspected pregnancy loss should only be confirmed after a follow-up scan at least 14 days later shows no embryo with cardiac activity (Grade C). In intrauterine pregnancies of uncertain viability with an embryo <7mm on transvaginal ultrasound, the suspected pregnancy loss should only be confirmed after a follow-up scan at least 7 days later (Grade C). In pregnancies of unknown location after transvaginal ultrasound (i.e. not visible in the uterus), a threshold of at least 3510IU/l for the serum human chorionic gonadotrophin assay is recommended; above that level, a viable intrauterine pregnancy can be ruled out (Grade C). Postponing conception after an early miscarriage in women who want a new pregnancy is not recommended (Grade A). A work-up for women with recurrent pregnancy loss should include the following: diabetes (Grade A), antiphospholipid syndrome (Grade A), hypothyroidism with anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies (Grade A), vitamin deficiencies (B9, B12) (Grade C), hyperhomocysteinaemia (Grade C), hyperprolactinaemia (Grade B), diminished ovarian reserve (Grade C), and a uterine malformation or an acquired uterine abnormality amenable to surgical treatment (Grade C). The treatment options recommended for women with a missed early miscarriage are vacuum aspiration (Grade A) or misoprostol (Grade B); and the treatment options recommended for women with an incomplete early miscarriage are vacuum aspiration (Grade A) or expectant management (Grade A). In the absence of both chorioamnionitis and rupture of the membranes, women with a threatened late miscarriage and an open cervix, with or without protrusion of the amniotic sac into the vagina, should receive McDonald cerclage, tocolysis with indomethacin, and antibiotics (Grade C). Among women with a threatened late miscarriage and an isolated undilated shortened cervix (<25mm on ultrasound), cerclage is only indicated for those with a history of either late miscarriage or preterm delivery (Grade A). Among women with a threatened late miscarriage, an isolated undilated shortened cervix (<25mm on ultrasound) and no uterine contractions, daily treatment with vaginal progesterone up to 34 weeks of gestation is recommended (Grade A). Hysteroscopic section of the septum is recommended for women with a uterine septum and a history of late miscarriage (Grade C). Correction of acquired abnormalities of the uterine cavity (e.g. polyps, myomas, synechiae) is recommended after three early or late miscarriages (Grade C). Prophylactic cerclage is recommended for women with a history of three late miscarriages or preterm deliveries (Grade B). Low-dose aspirin and low-molecular-weight heparin at a preventive dose are recommended for women with obstetric antiphospholipid syndrome (Grade A). Glycaemic levels should be controlled before conception in women with diabetes (Grade A).

[Hepatitis B and pregnancy. Part 1. Thirteen practical issues in antenatal period]. / Hépatite B et grossesse. Partie 1. Treize questions pratiques en période anténatale.

In France, the prevalence of chronic hepatitis B is about 1% in pregnant women (usually asymptomatic carriers of HBsAg). The risk of maternal-fetal transmission of hepatitis B is particularly high when viral load measured by PCR is higher in mothers (above 7 log) or HBeAg is present. In case of maternal-fetal transmission of hepatitis B, the risk to the newborn of developing subsequent chronic hepatitis B is very high (90%), with long-term complications such as cirrhosis and hepatocellular carcinoma. The prevention of maternal-fetal transmission is based on systematic testing for hepatitis B during pregnancy, followed by serovaccination of the newborn at birth. If necessary, amniocentesis can be realised but will avoid the realization of a transplacental gesture. In case of high viral load, the establishment of a maternal antiviral treatment with lamivudine or tenofovir from 28SA can further reduce the risk of transmission. Given the low resistance it induces, tenofovir should be used preferentially.

Systematic prophylactic oxytocin injection and the incidence of postpartum hemorrhage: A before-and-after study.

OBJECTIVE: Assess the impact of routine injection of 5 units of oxytocin as soon as the anterior shoulder is delivered on the incidence of postpartum haemorrhage (PPH) in a context of daily practice. MATERIALS AND METHODS: Single-centre before-and-after study evaluating the effect of a change in the protocol for PPH prevention as applied in our obstetrical unit. During the first period, oxytocin (5 units) was to be injected only in case of PPH risk factors. During the second period, the injection was systematic. RESULTS: In the "before" study period, there were 1953 patients vaginal deliveries and 843 (43%) oxytocin injections, with a protocol compliance of 85%. In the "after" study period, 2018 women had vaginal deliveries and 1911 (95%) had an oxytocin injection (protocol compliance: 95%). The whole study period was associated with a reduced risk of moderate haemorrhage (13.4% vs. 9.2%, P<0.001), but no significant reduced risk of severe haemorrhage was observed (2.1% vs. 2.0%, P=0.79). After logistic regression, the study period remained associated with a significant reduction in the risk of moderate PPH (OR=0.72 [0.58-0.89]). CONCLUSION: Routine injection of 5 units of oxytocin makes it possible to reduce the risk of moderate PPH, but it does not affect the risk of severe PPH.

Bulky fibroid and pregnancy: myomectomy is possible during pregnancy.

When bulky fibroids are discovered during pregnancy, they can become acutely complicated. The question of their resection thus arises. The authors report a case of a woman who was diagnosed at eight weeks' gestation by ultrasound and then by MRI, with a uterine fibroma measuring 22x12x15 cm.

[Twin pregnancy with complete mole and coexisting fetus: Reach fetal viability is possible]. / Grossesse gémellaire avec môle complète et fœtus sain coexistant : atteindre la viabilité fœtale est possible.

Twin pregnancies combining complete hydatidiform mole and coexistent fetus are a rare situation (incidence in 1/20,000 in 1/100,000 pregnancies) and a challenge for diagnosis. Their complications can be important - bleeding, preeclampsia, miscarriage - and their management remains complex and controversial. In case of continuing the pregnancy, nearly 40% of women have lives babies. Three quarters of fetal loss occur before 24weeks gestation. We report here three new cases; only one of these cases had a favorable outcome.

[Psychosocial vulnerability and substance use screening during pregnancy: Evaluation of a composite auto-questionnaire versus usual medical questioning]. / Dépistage des situations de vulnérabilité psychosociale et toxicologique pendant la grossesse : évaluation d'un auto-questionnaire par comparaison aux données du dossier médical.

AIM: To evaluate auto-questionnaire use for psychosocial vulnerability and substance use (smoking, alcohol consumption, depression, intimate violence) screening during pregnancy versus usual medical report. MATERIAL AND METHODS: An auto-questionnaire based on validated tests (Fagerström/HSI, T-ACE, EPDS, SSQ6) was proposed to 1977 pregnant patients at their first obstetrical consultation. We compared results of auto-questionnaire and usual medical questioning. RESULTS: The auto-questionnaire was filled by 1676 pregnant patients (89.4 %). The two Fagerström/HIS questions showed that 20.7 % smoked during pregnancy. T-ACE score was better than usual medical questioning to detect excessive alcohol consumption (4.0 % vs 0.1 %, P<0.05). Drug use before pregnancy was reported by 9.8 % patients in auto-questionnaire, but was only found in 4.9 % of medical files (P<0.001). Seven percent patients reported at least 3 depressive symptoms on 4 purposed in auto-questionnaire. Intimate violence, physical or psychological, was reported in 9.4 %. All of these vulnerability factors were linked together, in auto-questionnaire or in usual medical reports. CONCLUSION: Using auto-questionnaire based on standardized screening tests could help medical practioneers to detect psychosocial vulnerability and/or substance use during pregnancy.

[Epidemiology of loss pregnancy]. / Épidémiologie des pertes de grossesse.

OBJECTIVES: Study of epidemiology of pregnancy loss. MATERIALS AND METHOD: A systematic review of the literature was performed using Pubmed and the Cochrane library databases and the guidelines from main international societies. RESULTS: The occurrence of first trimester miscarriage is 12% of pregnancies and 25% of women. Miscarriage risk factors are ages of woman and man, body mass index greater than or equal to 25kg/m(2), excessive coffee drinking, smoking and alcohol consumption, exposure to magnetic fields and ionizing radiation, history of abortion, some fertility disorders and impaired ovarian reserve. Late miscarriage (LM) complicates less than 1% of pregnancies. Identified risk factors are maternal age, low level of education, living alone, history of previous miscarriage, of premature delivery and of previous termination of pregnancy, any uterine malformation, trachelectomy, existing bacterial vaginosis, amniocentesis, a shortened cervix and a dilated cervical os with prolapsed membranes. Fetal death in utero has a prevalence of 2% in the world and 5/1000 in France. Its main risk factors are detailed in the chapter.

[In utero fetal death]. / Morts fœtales in utero.

OBJECTIVES: To give consistent data of the prevalence of intrauterine fetal death (IUFD), to assess risk factors and causes related to IUFD, to evaluate prevention of IUFD, to evaluate fetal autopsy and MRI and to determine the management of inhibition of lactation. METHODS: French and English publications were searched using PubMed, Cochrane Library. RESULTS: Intrauterine fetal death occurs in 2% of the pregnancies worldwide, and in around 0,5% of pregnancies in France (NP1). Major risk factors related to IUFD are maternal overweight, maternal age, and smoking, small for gestational age fetuses or placental abruption, and pre-gestational maternal diseases such as hypertension and diabetes (NP1). The most relevant causes of IUFD are placental anomalies, followed by abnormal karyotypes and congenital malformations (NP3). Data are insufficient to recommend a classification for causes of IUFD. Data concerning primary and secondary prevention do not recommend a specific management for the following of pregnancy. Fetal autopsy is still the gold standard of fetal examination, but fetal post-mortem MRI can be offered when fetal autopsy is refused (NP4). Inhibition of lactation should be started within 24hours postpartum with cabergoline, if the patient demands a treatment (NP4).

[Polycystic ovary syndrome: what are the obstetrical risks?]. / Syndrome des ovaires polymicrokystiques: une pathologie à risque obstétrical?

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age and the leading cause of female infertility. This condition is frequently associated with significant metabolic disorders, including obesity and hyperinsulinemia. Therefore, it seems essential to focus on the pregnancy of these patients and possible obstetric complications. Many studies suggest an increase in the risk of obstetric pathology: early miscarriage, gestational hypertension, preeclampsia, gestational diabetes mellitus diagnosed during early pregnancy, prematurity, low birthweight or macrosomia, neonatal complications and cesarean sections. However, it is difficult to conclude clearly about it, because of the heterogeneity of definition of PCOS in different studies. In addition, many confounding factors inherent in PCOS including obesity are not always taken into account and generate a problem of interpretation. However it seems possible to conclude that PCOS does not increase the risk of placental abruption, HELLP syndrome, liver disease, postpartum hemorrhage, late miscarriage and stillbirth.

[Esophageal atresia: prevalence, prenatal diagnosis and prognosis]. / Atrésie de l'œsophage : prévalence, diagnostic anténatal et pronostic.

Esophageal atresia (EA) is a rare congenital malformation (1 in 2,500 to 3,500 births). Prenatal diagnosis (PN) is particularly interesting allowing search for associated malformations related to worse prognosis forms (reference ultrasound, MRI and amniocentesis) and planning the birth in an adapted medico-surgical center. Diagnosis of EA is usually suspected because of indirect and non-specific signs: association of polyhydramnios and absent or small stomach bubble. The visualization in ultrasound or MRI of cervical or thoracic fluid image corresponding to the expansion of the bottom of upper esophageal ("pouch sign") increases the specificity of diagnosis. However, prenatal diagnosis remains difficult and less than 50 % of EA are diagnosed prenatally. Biochemical analysis could improve these results. If EA is confirmed at birth, surgical management consists in a primary end-to-end anastomosis in first days of life, or in two-steps surgery if the defect is too large. Although current prognosis of EA is good, frequency of surgical complications and esophageal lesions secondary to gastroesophageal reflux justify a systematic and multidisciplinary extended follow-up.

[Interpretation of atypical values of maternal serum markers]. / Interprétation des valeurs atypiques des marqueurs sériques.

OBJECTIVES: Prenatal screening was set up to identify patients at high-risk of chromosome 21 trisomy based on maternal serum markers measurement. However, the risk of trisomy 21 should not be the only result considered by obstetricians. In fact, abnormal marker values can be associated with other fetal diseases and used to improve maternal and fetal follow-up. Our objective was therefore to study other predictive values of maternal serum markers. MEANS AND METHODS: A search through publications was conducted using the PubMed® or Cochrane® databases. RESULT: In case of high PAPP-A there is no link with any complications. Second trimester high hCG or first trimester low hCG are associated with an increased vascular risk. High α-fetoprotein level is a marker of neural tube defects or abdominal wall defect. Persistence of high α-fetoprotein with normal echography can suggest other rare fetal diseases. Low maternal serum markers suggests 18 trisomy. Oestriol reflects the fetal hypothalamo-hypophyseal axis and can be used as a diagnosis tool. CONCLUSION: Serum markers could be interesting tools for the identification of high-risk pregnancy and the prevention of neonatal complications. They also appear as a potential help to diagnose certain congenital malformations.

[Impact of bariatric surgery on obstetric prognosis]. / Impact de la chirurgie bariatrique sur le pronostic obstétrical.

OBJECTIVES: Assessment of pregnancy outcomes after bariatric surgery and analysis of follow-up particularities of such pregnancies. PATIENTS AND METHODS: A retrospective study of 63 post-bariatric surgery pregnancies compared to 259 pregnancies of obese un-operated patients. Pregnancy outcomes, neonatal datas, delay influence between surgery and pregnancy beginning, bariatric surgery type and gastric banding (GB) loosening consequences were analysed. RESULTS: In the surgical brand were developed less gestational diabetes (DG) (P=0,05), deliveries were more often normal (P=0,004) and births shown less macrosomias and small for gestational age newborns (P=0,04). Neonatal state was improved among operated patients: less Apgar scores less than 7 at 1 minute (P=0,05) and less cord blood pH less than 7,2 (P=0,03). They gained more weight during the pregnancy (P=0,0003) and only 53% had a nutritional management and assessment. Patients with GB loosening gained more weight (P=0,0003). Lastly, there were no difference due to the different bariatric surgery techniques or nutritional follow-up in the pregnancy course and neonatal state. DISCUSSION AND CONCLUSION: Bariatric surgery improves obstetric and neonatal prognosis. Improvements have to be developed in the multidisciplinary follow-up in order to avoid nutritional deficiencies or important weight gain pregnancy in case of GB.

Prevalence and risk factors of bacterial vaginosis during the first trimester of pregnancy in a large French population-based study.

OBJECTIVES: Bacterial vaginosis is a risk factor for preterm delivery. Its prevalence and risk factors in Europe are not well known. Our objective was to assess both in early pregnancy. STUDY DESIGN: As part of the PREMEVA randomized controlled trial, this population-based study included 14,193 women screened before 14 weeks' gestation for bacterial vaginosis in the 160 laboratories of the Nord-Pas-de-Calais region in France. Bacterial vaginosis was defined by a Nugent score ≥ 7. Data were collected about maternal tobacco use, age, education, and history of preterm birth. We estimated the prevalence of bacterial vaginosis and used a multilevel logistic regression model to identify significant risk factors for it. RESULTS: Among the 14,193 women assessed before 14 weeks' gestation, the prevalence of bacterial vaginosis was 7.1% (95% CI: 6.6-7.5%). In the multivariate analysis, smoking during pregnancy tobacco (adjusted OR: 1.38; 95% CI: 1.19-1.60), maternal age 18-19 years (adjusted OR: 1.40; 95% CI: 1.01-1.93), and educational level (completed only primary school: adjusted OR: 1.77; 95% CI: 1.35-2.31; completed only secondary school: adjusted OR: 1.27; 95% CI: 1.10-1.48) were independent risk factors for bacterial vaginosis. History of preterm delivery was not an independent risk factor of bacterial vaginosis: adjusted OR: 1.15; 95% CI: 0.90-1.47. CONCLUSION: In a large sample of women in their first trimester of pregnancy in France, the prevalence of bacterial vaginosis was lower than rates reported in other countries, but risk factors were similar: young age, low level of education, and tobacco use during pregnancy. These results should be considered in future strategies to reduce preterm delivery.

[Is the bacterial vaginosis risk factor of prematurity? Study of a cohort of 1336 patients in the hospital of Arras]. / La vaginose bactérienne est-elle facteur de risque de prématurité ? Étude d'une cohorte de 1336 patientes au centre hospitalier d'Arras.

BACKGROUND: Among risk factors of prematurity, bacterial vaginosis (BV) could play an important role, but few studies took place in our country. AIM: In a French population of women booking in a hospital maternity, to search a link between prematurity and BV in the first trimester of pregnancy. METHODS: A hospital cohort study was carried out between May 2006 and September 1(st), 2009. Pregnant women were screening for BV before 13+6 weeks' gestation. BV was determined by a Gram-Stained Vaginal score greater or equal to 7. RESULTS: One thousand three hundred and thirty-six patients were included in the study among whom 203 patients had BV and 1133 patients did not have. The presence of BV was significantly associated with preterm delivery (OR: 1.6; 95% IC: 1.1-2.7). But this increase concerned only the spontaneous prematurity (ORa: 1.8, 95% IC: 1.0-3.2) and the statistical association disappeared after taking into account maternal tobacco addiction and socio-economic weak level (ORa: 1.6; 95% IC: 0.9-2.9). At the patient with BV, moreover, the risk of miscarriage before 16SA was significantly augmented at the patient with BV (OR: 3.4; 95% IC: 1.1-10.4), but this risk disappeared after taking into account tobacco addiction and maternal level of studies (ORa: 1.9; 95% IC: 0.5-7.2). CONCLUSION: The presence of BV in the first trimester of pregnancy seems to be associated with increased risks of preterm delivery and early spontaneous miscarriage. However, this relation seems to be partly linked to a level of weaker study and a more frequent tobacco addiction among the women with BV.

Oculo-dento-digital dysplasia: lack of genotype-phenotype correlation for GJA1 mutations and usefulness of neuro-imaging.

Oculo-dento-digital dysplasia (ODDD) is an autosomal dominant disorder with complete penetrance and high intra- and interfamilial phenotypic variability. The key features in this syndrome are microphthalmia, enamel hypoplasia and syndactyly of the 4th-5th fingers. ODDD is caused by mutations in the connexin 43 gene (GJA1). We report here four patients from three families with GJA1 mutations, one of them diagnosed prenatally. The three mutations (c.52T > C/p.Ser18Pro, c.689_690delTA/p.Tyr230CysfsX6, c.442C > G/p.Arg148Gly) have been reported once before. Two patients had white matter hypersignal anomalies, associated in one case with mental retardation, but asymptomatic in the other one, an observation that leads us to discuss systematic neuroradiological imaging for ODDD. One case has optic atrophy, another has hypospadias. The patient carrying a truncating mutation of Cx43 did not have palmoplantar keratoderma, in contradiction with the previously suggested genotype-phenotype correlation between truncating mutation and skin involvement.

[Prevention of early-onset group B streptococcus neonatal diseases. The 2005 experience of the Lille University Health Center]. / Prévention des infections bactériennes néonatales précoces à streptocoque B. L'expérience du CHRU de Lille en 2005.

OBJECTIVES: To study the efficiency of the official recommendations on the prevention of group B streptococcus and the impact of this strategy. MATERIALS AND METHODS: A prospective study was realized in 2005. All infants who were live-born at the Jeanne-de-Flandre hospital (Lille, France) and their mothers were included in the study. Data concerned both pregnancy (vaginal screening, intrapartum antibiotic) and newborn (safe, colonization and early-onset neonatal bacterial disease). RESULTS: Our study included 4353 mother-newborn couples. Vaginal screening was performed on 92% of the women included in the study. Prevalence of vaginal group B streptococcus in screened women was 7%. Perpartum antibioprophylaxia of group B streptococcus was achieved in 12% of the women included in the study. Group B streptococcus was associated to 60% of probable and certain early-onset bacterial neonatal diseases, with an incidence of 9/1000 births. Exposition to antenatal antibiotherapy multiplied by two the risk of ampicillin resistant Gram-negative bacilli (RR=2 [1.1-3.8]). CONCLUSION: Recommendations were well followed, but in our health center group, B streptococcus was the main bacteria responsible for early-onset bacterial neonatal diseases. Because of the risk of germ selection, a more targeted antibioprophylaxia has to be preferred.

[Consequences of premature rupture of the membranes in the perinatal lung]. / Physiopathologie des conséquences respiratoires néonatales de la rupture prématurée des membranes: application à la prise en charge néonatale.

Early premature rapture of the membranes (PROM) during pregnancy is associated with a high risk of perinatal morbidity and mortality. Early PROM impairs lung structures and function through 3 mechanisms : 1) oligo-hydramnios ; 2) fetal inflammatory syndrome ; and 3) prematurity. Thus, the related causes of respiratory failure at birth after PROM are: hyaline membrane disease, persistent pulmonary hypertension induced by impaired endothelial function and/or lung hypoplasia, materno-fetal infection, and bronchopulmonary dysplasia resulting at least in part from the fetal inflammatory syndrome. Severity of the respiratory morbidity is largely unpredictable. Even if gestational age at PROM is considered as a prognostic factor, survival without morbidity exist after PROM as early as 18 weeks GA. Better knowledge of the pathophysiology improved the outcome of the preterm infants born after early PROM. Optimal management of the respiratory failure including minimizing barotrauma is required to prevent from bronchopulmonary dysplasia.